tbuckley/cabot-search huggingface dataset:
In-Training Examination in Internal Medicine
Authors: Richard A. Garibaldi
Journal: Annals of Internal Medicine (1995)

Letters1 January 1995In-Training Examination in Internal MedicineRichard A. Garibaldi, MD, Herbert S. Waxman, MD, and D. Theresa Kanya, MBARichard A. Garibaldi, MDUniversity of Connecticut Health Center; Farmington, CT 06030-3950Albert Einstein Medical Center; Philadelphia, PA 19141-3025American College of Physicians; Philadelphia, PA 19106-1572Search for more papers by this author, Herbert S. Waxman, MDUniversity of Connecticut Health Center; Farmington, CT 06030-3950Albert Einstein Medical Center; Philadelphia, PA 19141-3025American College of Physicians; Philadelphia, PA 19106-1572Search for more papers by this author, and D. Theresa Kanya, MBAUniversity of Connecticut Health Center; Farmington, CT 06030-3950Albert Einstein Medical Center; Philadelphia, PA 19141-3025American College of Physicians; Philadelphia, PA 19106-1572Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-122-1-199501010-00034 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:In a voluntary examination such as the ITE-IM, selection bias may influence test scores over time. It is possible that “better” programs offered the examination to their interns when the test first became available and that the recent decrease in scores among first-year housestaff who have graduated from medical schools in the United States reflects the fact that the examination is now being administered by a wider array of programs. It should be noted, however, that the decrease in scores is less evident among interns who have graduated from international medical schools. On the 1994 ITE-IM, the downward ...References1. Sosenko J, Stekel KW, Soto R, Gelbard M. NBME examination part I as a predictor of clinical and ABIM certifying examination performance. J Gen Intern Med. 1993; 8:86-8. Google Scholar2. Grossman RS, Fincher RE, Layne RD, Seelig CB, Berkowitz LR, Levine MA. Validity of the in-training examination for predicting American Board of Internal Medicine certifying examination scores. J Gen Intern Med. 1991; 763-7. Google Scholar3. Waxman H, Braunstein G, Dantzker D. Performance on the internal medicine second-year residency in-training examination predicts the outcome of the ABIM certifying examination. J Gen Intern Med. 1994; (In press). Google Scholar Author, Article, and Disclosure InformationAffiliations: University of Connecticut Health Center; Farmington, CT 06030-3950Albert Einstein Medical Center; Philadelphia, PA 19141-3025American College of Physicians; Philadelphia, PA 19106-1572 PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 January 1995Volume 122, Issue 1Page: 73-74 ePublished: 15 August 2000 Issue Published: 1 January 1995 Copyright & PermissionsCopyright © 1995 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...
Purification of a newly identified alkaline sphingomyelinase in human bile and effects of bile salts and phosphatidylcholine on enzyme activity
Authors: R Duan
Journal: Hepatology (1997)

The hydrolysis of sphingomyelin (SM) generates important signals regulating cell proliferation and apoptosis. Acid and neutral sphingomyelinases (SMase) have been identified and their biological effects intensively studied. We recently found in human bile a novel alkaline SMase that may have important roles in hepatobiliary diseases. In this work, we purified the enzyme and studied the factors influencing enzyme activity. Purification steps included Sephadex G25, diethylaminoethyl (DEAE)-Sepharose, Sephacryl S-200, and sphingosylphosphorylcholine (SPC) affinity chromatographies. A single protein of 92 kd was obtained with the specific enzyme activity increased 1,154-fold. The enzyme specifically hydrolyzed SM to ceramide, had a weaker activity against phosphatidylcholine (PC), and no activity against either phosphatidylethanolamine (PE) or p-nitrophenyl phosphate. Its optimum pH was 9.0 and its Vmax and Km were 45 micromol/h/mg and 2.5 × 10-5 mol/L, respectively. The enzyme activity was dependent on concentration and structure of bile salts. Both trihydroxy and dihydroxy bile salts at concentrations up to their critical micellar concentrations activated the alkaline SMase, trihydroxy bile salts being more potent than dihydroxy ones. The side chain of trihydroxy bile salts was also important. Taurocholate (TC) was most effective in activating SMase, followed by glycocholate (GC), and cholate. 3-((3-cholamidopropyl)dimethylammonio)-propanesulfonate (CHAPS) alone had no effect on SMase activity but inhibited TC-induced activation of SMase. PC competitively inhibited bile alkaline SMase activity, with the 50% inhibition occurring at a PC/SM ratio of approximately 28. In conclusion, we purified a novel alkaline SMase from human bile and found that its activity is dependent on the levels of two major biliary components: PC and bile salts.
Family history, age, and risk of breast cancer. Prospective data from the Nurses' Health Study
Authors: G. A. Colditz
Journal: JAMA (1993)

<h3>Objective.</h3> —To examine prospectively the risk of breast cancer as influenced by a maternal history of breast cancer, the mother's age at diagnosis, or a sister's history of breast cancer. <h3>Design.</h3> —Prospective cohort study with biennial follow-up. <h3>Setting/Participants.</h3> —117988 women in the Nurses' Health Study aged 30 to 55 years in 1976, followed up through 1988 (1.3 million person-years of follow-up). <h3>Results.</h3> —We identified 2389 incident cases of invasive breast cancer. Compared with women without a maternal history of breast cancer, the age-adjusted relative risk (RR) of breast cancer was highest among women whose mother was diagnosed before the age of 40 years (RR, 2.1 [95% confidence interval, 1.6 to 2.8]). The RR decreased with advancing maternal age at time of diagnosis to 1.5 (95% confidence interval, 1.1 to 2.2) for maternal diagnosis after the age of 70 years. Having a sister with a history of breast cancer also was related to increased risk; for women with one sister with breast cancer compared with those with one sister without such a history, the age-adjusted RR was 2.3 (95% confidence interval, 1.6 to 3.4). Women whose mother and sister both had a history of breast cancer had an RR of 2.5 (95% confidence interval, 1.5 to 4.2) compared with those without a family history. These associations did not differ appreciably when stratified by age; menopausal status; history of benign breast disease; body mass index; age at menarche; or parity or age at first birth of the women at risk. The results remained unchanged when we controlled for these risk factors in multivariate models. Despite slightly greater mammography surveillance and earlier detection of tumors among women with a family history of breast cancer, detection bias is unlikely to account for more than a small part of the observed association. <h3>Conclusions.</h3> —Risk of breast cancer is approximately doubled among women whose mother had breast cancer diagnosed before the age of 40 years or who have a sister with breast cancer, and remains elevated even for those whose mothers were diagnosed with breast cancer at the age of 70 years or older. However, the risk associated with a mother or sister history of breast cancer is smaller than suggested by earlier retrospective studies. Overall, within this population of middle-aged women, only 2.5% of breast cancer cases are attributable to a positive family history. (<i>JAMA</i>. 1993;270:338-343)
A Rapidly Enlarging Nodule on the Dorsal Aspect of the Nose—Diagnosis
Journal: JAMA Dermatology (2013)

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Dermatology HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Dermatology journal
Histone hypercitrullination mediates chromatin decondensation and neutrophil extracellular trap formation
Authors: Yanming Wang, Ming Li, Sonja Stadler, Sarah Correll, Pingxin Li, Danchen Wang, Ryo Hayama, Lauriebeth Leonelli, Hyunsil Han, Sergei A. Grigoryev, C. David Allis, Scott A. Coonrod
Journal: The Journal of Experimental Medicine (2009)
Southwest Oncology Group Study S0910: A Phase 2 Trial of Clofarabine/ Cytarabine/ Epratuzumab for Relapsed/ Refractory Acute Lymphocytic Leukemia.
Authors: Anjali Advani, Shannon McDonough, Steven Coutre, Brent L. Wood, Jerald P. Radich, Martha Mims, Margaret O'Donnell, Stephanie Elkins, Michael W. Becker, Megan Othus, Frederick R. Appelbaum
Journal: Blood (2012)
Early Egyptian Medical Practices
Journal: JAMA (1988)

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
THE NECESSITY FOR REORGANIZATION OF OUR LARGE HOSPITAL SERVICES.
Journal: JAMA (1903)

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
PATHOLOGY OF THE CEREBRAL VESSELS. ESPECIALLY IN RELATION TO MENTAL DISEASES.
Journal: JAMA (1900)

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
Zinc-Mediated Reduction of Apoptosis in Cardiac Allografts
Authors: Murray H. Kown, Tim Van der Steenhoven, Francis G. Blankenberg, Grant Hoyt, Gerald J. Berry, Jonathan F. Tait, H. William Strauss, Robert C. Robbins
Journal: Circulation (2000)

Background —Apoptosis is thought to occur during immune-mediated acute rejection of cardiac allografts. In vitro studies have shown that zinc inhibits the activity of the proapoptotic enzyme caspase-3. We hypothesized that ZnCl 2 would reduce acute cardiac rejection in vivo via the blockade of caspase-3–dependent apoptosis. 99m Tc-labeled annexin V was used to measure apoptosis in cardiac allografts through nuclear imaging. Annexin V binds to phosphatidylserines, which are externalized to the outer membrane of apoptotic cells. Methods and Results —Twenty-seven PVG rat hearts were transplanted heterotopically into the abdomen of untreated ACI rats as controls (group 1). Fifteen were scanned and euthanized on postoperative day 4, and 12 were assessed for graft survival. Group 2 and 3 rats (n=15 each) received 1 and 5 mg/kg ZnCl 2 BID IP, respectively. Nine of each of these groups were scanned and euthanized on postoperative day 4, and 6 were studied for allograft survival. Group 4 rats (n=3) received isografts. Region-of-interest analysis demonstrated a dose-dependent reduction in 99m Tc annexin uptake in ZnCl 2 -treated allografts: 2.43±0.37% for group 1, 1.97±0.41% for group 2, 1.21±0.47% for group 3, and 0.55±0.19% for group 4 (ANOVA, P =0.001). Graft survival times of 6.4±1.7, 9.3±3.0, and 11.5±3.4 days for groups 1, 2, and 3, respectively, were also observed (ANOVA, P =0.001). Caspase-3 activity in the allografts showed a 3.7-fold reduction in group 3 animals compared with group 1 animals ( P =0.004). Conclusions —Apoptosis that occurs in acute cardiac allograft rejection is reduced with ZnCl 2 in a dose-dependent manner via caspase-3 inhibition.
Strep Virulence
Authors: Tracy Hampton
Journal: JAMA (2007)

A novel cell-binding strategy by Streptococcus pneumoniae points to this pathogen's mechanism of attack, report researchers at the University of Victoria, in British Columbia (van Bueren AL et al. Nat Struct Mol Biol. doi:10.1038/nsmb1187 [published online December 24, 2006]).
Portrait of a Woman With a Book of Music
Journal: JAMA (2004)

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
IMMUNOLOGICALLY PRIVILEGED?
Journal: JAMA (1964)

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
Clinical Urinology.
Journal: JAMA (1905)

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
THE EXPERIMENTAL FORMATION AND TREATMENT OF CALCULI
Journal: JAMA (1927)

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
Autumn Equinox
Authors: Floyd Skloot
Journal: JAMA (1997)

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
Breath sounds
Authors: P. Forgacs, A. R. Nathoo, H. D. Richardson
Journal: Thorax (1971)

Breathing is silent in health but audible at a distance in chronic bronchitis and asthma. This clinical observation was tested by measurements of the intensity of the inspiratory breath sounds at the mouth at flow rates up to 60 1./min. There was a higher rate of increase in the intensity of the sound for equal increments in flow rate in these two diseases than in healthy subjects. Bronchodilator drugs reduced the intensity of abnormally loud inspiratory sounds. The noise is generated by turbulent flow of air in the upper respiratory tract, the trachea, and the central bronchi. Reduction of bronchial calibre increases flow velocity and intensifies turbulence. The intensity of the inspiratory sound in chronic bronchitis and asthma reflects calibre changes in the trachea, the principal bronchi, and their lobar and segmental branches. An inverse correlation exists between the intensity of the inspiratory sound, the forced expiratory volume in one second, and the peak expiratory flow rate in chronic bronchitis and asthma, but not in primary emphysema. Discrepancies between sound, airway resistance, and forced expiratory measurements may indicate the site and mechanism of airway obstruction in individual patients. The sound of inspiration heard with the unaided ear close to the patient9s mouth is an important clinical sign. Noisy inspiration is common in chronic bronchitis and asthma, and the degree of narrowing of the central bronchi can be inferred from the loudness of the noise. Silent inspiration in the presence of severe expiratory obstruction is a sign of primary emphysema.